【摘要】：目的分析影響左心瓣膜置換術(shù)后遠期重度三尖瓣關(guān)閉不全再次行三尖瓣手術(shù)患者圍手術(shù)期死亡和遠期生存的因素,探討再次手術(shù)的恰當(dāng)時機。方法收集2001年1月至2015年12月在我院胸心外科因左心瓣膜置換術(shù)后重度三尖瓣關(guān)閉不全面再次行三尖瓣手術(shù)治療的111例患者的臨床資料,并對術(shù)后生存的患者進行隨訪,分析影響患者圍手術(shù)期死亡和遠期生存的危險因素。結(jié)果 (1) 11例(9.9%)行三尖瓣成形術(shù),100例(90.1%)行三尖瓣置換術(shù),其中機械瓣置換45例,生物瓣置換55例。圍手術(shù)期死亡11例,死亡率為9.9%,死亡原因為呼吸功能衰竭2例,腎功能衰竭1例,心功能衰竭3例,多器官功能衰竭5例。單因素分析顯示術(shù)前頑固性右心功能不全(P=0.015)、NYHA心功能IV級(P=0.002)、肺動脈高壓(P=0.008)、左心室射血分數(shù)(P=0.016)、血清肌酐(P0.001)、總膽紅素(P=0.042)、白蛋白(P=0.020)與圍手術(shù)期死亡有關(guān)。多因素Logistic回歸分析顯示頑固性右心功能不全(OR:44.075,95%CI: 2.602-746.60 2, P=0.009)、肺動脈高壓(OR:79.886,95%CI:2.709-2355.405,P=0.011)、左心室射血分數(shù)0. 5(OR:29.278,95%CI: 1.413-606.765,P=0.029)、白蛋白35g/L(OR: 21.757,95%CI: 1.246-379.886,P=0.035)是影響圍手術(shù)期死亡的獨立危險因素。(2)圍手術(shù)期生存100例患者,隨訪率95%,隨訪時間8-186個月,平均59.2±39.5月。隨訪中有10例死亡,其中6例死于心功能衰竭,1例死于感染性心內(nèi)膜炎,1例死于腦出血,1例死于腦卒中,1例發(fā)生猝死。術(shù)后1年,5年,10年的累積生存率分別為98.0%, 88.0%, 73.3%。單因素分析顯示術(shù)前頑固性右心功能不全(Log-rank P0.001)、NYHA 心功能Ⅳ級(Log-rankP=0.026)、左心室射血分數(shù)0.5(Log-rank P=0.020)、血肌酐110μmol/L(Log-rank P=0.017)、白蛋白35g/L(Log-rank P=0.037)是影響術(shù)后生存的危險因素。多因素Cox回歸分析結(jié)果顯示,術(shù)前頑固性右心功能不全為影響術(shù)后生存的獨立危險因素(HR:7.451,95%CI:2.204-25.190,P=0.001)。(3)術(shù)后免于主要心臟不良事件(MACE)的1年,5年,10年累積生存率分別為98.0%,79.9%,63.7%。單因素分析顯示術(shù)前頑固性右心功能不全(Log-rank P0.001)、NYHA 心功能Ⅳ級(Log-rankP=0.021)、左心室射血分數(shù)0.5(Log-rank P=0.032)、血肌酐110μmol/L(Log-rank P=0.013)、白蛋白35g/L(Log-rank P=0.034)是影響術(shù)后患者遠期免于主要心臟不良事件生存率的危險因素。多因素Cox回歸分析結(jié)果顯示,術(shù)前頑固性右心功能不全(HR:4.705,95%CI:2.193-10.093,P0.001)、血肌酐110μmol/L (HR:3.422,95%CI: 1.044-11.219, P=0.042)為影響術(shù)后遠期免于主要心臟不良事件生存率的獨立危險因素。(4)對于術(shù)后生存的90例接受三尖瓣置換術(shù)(TVR)的患者,機械瓣組(41例)和生物瓣組(49例)的術(shù)后累積生存率的差異無統(tǒng)計學(xué)意義(Log-Rank P=0.754)。兩組患者術(shù)后遠期免于主要心臟不良事件的累積生存率的差異也無統(tǒng)計學(xué)意義(Log-Rank P=0.726)。結(jié)論 (1)術(shù)前頑固性右心功能不全、肺動脈高壓、左心室射血分數(shù)0.5、白蛋白35g/L是影響圍手術(shù)期死亡的獨立危險因素。(2)術(shù)前頑固性右心功能不全為影響術(shù)后遠期生存的獨立危險因素。(3)術(shù)前頑固性右心功能不全、血肌酐110μmol/L為影響術(shù)后免于主要心臟不良事件生存率的獨立危險因素。(4)對于左心瓣膜置換術(shù)后重度三尖瓣關(guān)閉不全的患者,手術(shù)時機應(yīng)選擇在患者右心功能未發(fā)生不可逆性損害,肝腎功能未出現(xiàn)明顯異常時積極手術(shù)治療,可能使患者受益。
[Abstract]:Objective To analyze the factors influencing the perioperative death and long-term survival of tricuspid valve replacement in patients with tricuspid insufficiency after valve replacement. Methods The clinical data of 111 patients with severe tricuspid valve closure after aortic valve replacement after valve replacement in our hospital from January 2001 to December 2015 were collected, and the patients who survived were followed up. The risk factors of perioperative death and long-term survival were analyzed. Results (1) 11 cases (90.9%) underwent tricuspid valve replacement, 100 cases (90. 1%) underwent tricuspid valve replacement, in which 45 cases were replaced by mechanical flap and 55 cases with bioprosthesis replacement. The death rate was 9. 9% in 11 cases of perioperative death. The cause of death was respiratory failure (2 cases), renal failure (1), cardiac failure (3 cases) and multi-organ failure (5 cases). The single factor analysis showed that the left ventricular function was not complete before operation (P = 0. 015), NYHA class IV (P = 0. 002), pulmonary hypertension (P = 0.0008), left ventricular ejection fraction (P = 0.0016), serum adiponectin (P0. 001), total bilirubin (P = 0. 034) and albumin (P = 0.020) were associated with perioperative mortality. Multiple logistic regression analysis showed that refractory right ventricular function was incomplete (OR: 44. 967, 95% CI: 2.602-746. 60 2, P = 0.00009), pulmonary hypertension (OR: 79. 886, 95% CI: 2. 709-2355. 405, P = 0.011), left ventricular ejection fraction 0. 5 (OR: 29. 278, 95% CI: 1. 413-606. 765, P = 0.01), albumin 35g/ L (OR: 21. 757, 95% CI: 1. 246-379. 886, P = 0. 034) was an independent risk factor affecting perioperative mortality. (2) In the perioperative period of 100 patients, follow-up rate was 95%, follow-up time was 8-186 months, average 59. 2 72.39. 5 months. Among them, 10 died in follow-up, 6 of them died of cardiac failure, 1 died in infective endomyosis, 1 died in cerebral hemorrhage, 1 died in stroke, and 1 patient died of sudden death. 1-year, 5-year and 10-year cumulative survival rates were 98.0%, 88.0%, 73.3%, respectively. The single factor analysis showed that the left ventricular function was not all the same (Log-type P0.001), NYHA class 鈪，

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